Why You Didn’t Get Accepted to CRNA School: What Admissions Are Really Looking For

Many aspiring CRNAs interpret rejection personally, but admission committees are actually making predictive decisions about success. What these admission committees are asking is, quote unquote, based on the documented evidence in front of us, what is the probability this applicant will succeed in a program that does not slow down? Welcome back to the CRNA Mentor Podcast. I'm thrilled to be joined today with Dr. Mike McKinnon. Mike McKinnon is a practicing nurse anesthesiologist educator, and national leader in anesthesia policy and workforce innovation. He serves as an associate professor and the assistant director at National University CRNA program and holds additional faculty appointments at Idaho State University, New Mexico State University, and other institutions. He is a fellow of the American Association of Nurse Anesthesiology. He served on the ANA Board of Directors and has authored numerous peer-reviewed articles and national publications on anesthesia practice, healthcare economics, and rural access to care. Dr. McKinnon also hosts the award-winning podcast Anesthesia Deconstructed and a Substack publication, Just Gas. Today we're going to be discussing one of his Substack articles. The title is Didn't Get Accepted to a CRNA Program? Read This First, Part 1: How Admissions Actually Work. And this is an article, uh, Dr. McKinnon has co-authored with Matthew Harmon, Daniel King, David Warren, Lee Ranalli, and Richard Wilson. Welcome to the podcast, Mike.

Great to be here, Tyler.

Yeah, I'm happy to have you and I'm happy to explore this Substack article. This is something that, you know, Substack is brand new to me and I'm so glad I found it because it seems that all the, you know, big voices in anesthesia are writing these Substack articles. And this one today, it really hit, you know, talking about admissions for all of our aspiring nurse anesthetists and everybody within the CRNA Mentor platform, this is pure gold. Today, Mike, I wanna ask you, and this is from your article, you know, you say something that I think many applicants misunderstand, quote unquote, "The minimum requirements make you eligible, not competitive." Can you elaborate on that a little bit?

Yeah, absolutely. I think what a lot of people think when they're looking at any kind of thing that they wanna go into is that there's a bare minimum. If I meet that, then I'm eligible to get into the program. Whatever that program is, it has nothing to do with Nurse anesthesiology, it could be anything, right? But the truth of the matter is programs look at individual applicants amongst the pool of applicants that they get. So, you know, if I have an applicant who meets the bare minimum, many programs have a bare minimum GPA of somewhere around between 3 and 3.5, with science GPAs between 3 and 3.5, with a minimum of 1 year of critical care or, you know, experience. And, But the truth of the matter is the vast majority will have GPAs in the 3.6 to 3.9 range with science GPAs in the same range and 3 years on average of experience before they ever get into a program. Now that doesn't mean that some people don't get in earlier, but the truth of the matter is, you know, if I'm as a program administrator looking at applicants, I'm trying to figure out from a very small window onto who they are and what they've accomplished, are they gonna A, be successful in the program, they're gonna graduate, they're gonna be able to manage the self-evaluation exam, the C, and the NC, the National Certification Exam, and pass it? Because that's what my program is judged on, that's the bar, right? That's also the bar for them because you can't practice if you can't pass certification exam.

Okay.

So, you know, that's a lot of student loan if you never get to work as a CRNA. It is part of my fiduciary duty to them to make sure they're successful. You know, no different than hiring someone for a job, and I've done that too. Am I going to take the person with 1 year experience or the person with 5 years that's been working independently the whole time to come work in my independent practice? I think that's a no-brainer. Everyone's going to pick the person with 5 years, everything else being equal. And that's really what it means, right?

And that's a fair statement. You know, I often have these conversations, and, uh, you know, there's 2 schools of thought that people offer. It's like, you know, do I, do I just try and apply with the minimum experience and shoot my shot and see if I can get in, or do I build out my resume and, and try and give it, you know, this, this best effort, you know, the first time? And when I would approach CRNA school, I did the latter. You know, I'm like, I want to be confident going into this that I've done as many things possible to stand out, because quite frankly, I, I don't want to be told no. And I don't know, is it fair to say you operate from the same perspective here?

Yeah, I do. I mean, I totally get what you're saying and I understand their perspective. You know, hey, look, if I throw it out there and do the application, I'll get the experience of doing the application. Maybe I'll get an interview, I'll get the experience of having an interview. And sometimes there is more to applicants than just those things. You know, like we've had people apply to our program who've been physicians in other country, critical care physicians. Now they have 1 year of critical care nursing experience, but they have a great GPA and they've got all this background. That's someone I might be willing to do an interview with that I otherwise wouldn't without that special background. Or we've had athletes, you know, people who have competed at high level. You know, these are people that know how to work, right? There's a whole separate portion that I'm trying to determine when I'm looking at applicants. And a lot of that has to do with their gumption, their ability, their grind, right?

Mm-hmm.

And so I can't know that until I talk to them. I can see what I think it might be, on the resume. So do I think it's okay to go ahead and apply with 1 year experience and the minimums? Sure. I think that it's a shot in the dark, but the truth of the matter is you've got to stand out as a bright light in the dark night amongst hundreds of others. Otherwise, there's no chance that you're going to end up in an interview or get accepted. So there has to be something special to get you in then.

Certainly. And I love, you know, you talking about athletes because I do, you know, that was part of my background and it's something I see in others that, you know, you competed at a collegiate level, you there's something that you understand about teamwork, about the dynamic, and that's exactly what the operating room is. You can say the same and even more so for our individuals with any sort of like military background, I'm sure as well, just having that other look at what it is to be part of the team.

Yeah, and the grind that comes with those things, right?

Sure.

Getting up in the morning to do camp, the spending all your summers doing camp, going on a deployment and learning how to manage all this sort of stuff in a team, in a, in a hierarchy, which healthcare really does have some degree of a hierarchy. And so those are the things, you know, certainly within anesthesia school, you drop from being the expert in the ICU, the ER, or the helicopter to being the least important person in the room. It's hard to swallow that, but you learn that in a team dynamic environment, especially like the military or a sports team.

Mm-hmm, certainly, yeah. Yeah, I think an important part of this conversation, Mike, is, you know, understanding the math behind how the selection process actually is. And this is something that you, you mentioned in the article, but could you elaborate on that just for context here?

Yeah, sure. Every program does this kind of differently, and it's usually experiential-based from their perspective and what has worked for them, but the way the math works for us and at many of the programs that have been involved in is we do a point value system based upon every part of the metric of someone applying, right? And, and that is all based upon what we have seen has been successful over time, but is also in the data of being successful. So here's an example. You know, we talked about experience and some people will say, yeah, I've only got 1 year experience, but I got a 4.0 GPA and all these other things. Well, I mean, anyone who's worked in the hospital for any length of time knows that the person with 1 year experience, no insult to them, they could be the best, best, you know, hardest grinder, is not the person that anybody's going to.

Yeah.

When critical things happen, right? You're going to the person who's been there, done that, managed it, and stays calm under pressure. And calm under pressure comes with experience, right? You don't rise to the occasion. That is a false statement. You fall to your level of training and experience. And that is the reality in anesthesia and healthcare critical situations. And so we add a point value. You can get so many points up to a certain number of years. The maximum is really 5. After 5, there's probably diminishing returns. And that has a lot to do with the 10,000-hour expert-novice to expert sort of data that's out there. And then one of the other things, GPA. One of the things that we've seen that has been critically important in getting high scores on the C exam, which translate by correlation to passing the NCE exam, is a high science GPA. You know, I mean, if you took Basket Weaving 101 and got A's and then 102 and got A's, I don't care, right? Like, I have no interest in those. I'm not even going to look at it. But— What your science GPA is. Now that's important to me because those courses, no matter where you take them, are not easy, right? You can't just phone them in.

Yeah.

And so what that says is you can grind, you can make it happen, and you can understand difficult, deep concepts and do well, right? When you get an A. Some of the other things are, you know, just general background information. So, you know, someone who's lived a little bit more than the person who graduates, goes to nursing school, gets 1 year experience, and knows nothing else but that. There is a value there that is very, very hard to put a percentage on, right? But there's an ROI to life experience that really we have seen over and over again gets people across the line, right? Knowing that you've done something else, these second career individuals, like we've had people who have had MBAs, worked in economics. We've had people who have had PhDs. We've had physicians, with all these people with second— in their second career, they come with much more of an understanding of, I've got to make it happen for myself because this level of education, the expectation is you're self-directed. I mean, that's just the reality, right? You've got to put the grind in.

Yeah.

And then there's the interview, right? So, all of those things, those are all things I get from a piece of paper generally. But then when I get them to the interview, the stellar candidate may be the failing candidate. In the interview. You can lose it all there, or you could be the marginal candidate on paper, but get to the interview and just be phenomenal and we accept you, you know? And so there's something in the interview where we ask, we ask, for instance, critical care related questions based upon the unit or the ER or the helicopter, whatever they did. And we ask them questions and see if they can nail them. And if they don't nail them, how they respond to not nailing them. Do you just try to make it up as you go along? 'Cause that's not good, right? Or do you say, you know what, I'm not sure, but this is what I'm thinking and I'll get back to you with the right answer. That is just as important as nailing the question because that is self-reflection.

I agree with you 100%. I think a lot of it, I really talk about how the interview is where the rubber meets the road here and you don't have to be perfect in your interview. It's how you respond when you're not. Right, and I think that's exactly what you're describing. And yeah, no, that's great. As we look at the application process too, one of the things that I wanted to touch on was, you mentioned, say you have 800 applicants and you interviewed 100 and you accept a small amount of that. Looking at the acceptance rate compared to our MDs, DOs, other dental school out there, I think that really framed this discussion in a meaningful way that, it kind of explains the article itself, right? That it's super competitive and just because you kind of meet the criteria, it's just that competitive.

Yeah, it's not enough to be the bare minimum, right? You know, the bare minimum is what might make it so you can apply, but it's not what gets you across the line. You know, what gets you across the line is exceptionalism. And so, you know, if someone has exceptionalism in many different categories, it can be one, the other, multiple, that can get you across the line. And what you said is absolutely true. True, the final test is where the rubber meets the road, and that's the interview. And so, you know, the truth of the matter is there's no simple formula to this because all of the things you look at before you get to the interview can fail on the interview from someone who's accepting people, or all the things you look at before you get to the interview make you think, well, you know, we'll take a flyer on this person. They get to the interview and they're just phenomenal, right? We call them rockstar candidates, right?

Right.

When they nailed the interview, and these are people that will sometimes offer acceptance right at the end of the interview. We're also impressed with the individual, and that's entirely because of how well they do there, right? 'Cause interpersonal skills are just as important in the OR as your ability to manage, you know?

Yep, yep. Mike, in the article you said if someone receives a C in a prerequisite science course, they should retake that course and earn an A. Why is this important from an admission perspective?

Well, I think what it does is it tells us two things, right? It tells us that someone, you know, The people who are most successful in this world, when asked what they would do to be successful, the answer is whatever it takes, right? And so, that tells us that these individuals are willing to go back to redo something they did poorly at, to spend the money, to spend the time, to put the effort in, to nail it, right? To own it and then to be successful at it. That to me says something about the individual. Let's separate the GPA from it, right?

Mm-hmm.

That says that when you were asked what you would do to be successful, the answer was whatever it takes. And whatever it takes is going to be partially explaining to me why you did poorly in your past, because we've all been there, right? I mean, I would probably never get accepted to anesthesia school today. And the truth of the matter is, is, you know, you have to be able to explain or make up for or show that you can, you know, surmount the obstacles in your past. And that's part of what retaking these courses are. They tell me that not only was that an anomaly, anomaly, and it was a time in your life where, I don't know, you were busy partying in university, you weren't taking it seriously, you didn't really care. A's, A's weren't the thing. C's get degrees. You know, I mean, that's the way you were thinking because you're young and that's— you're having a great time and you got— you became an RN, right? Um, and so if that's one thing it tells us, it tells us that you're willing to do whatever it takes. The other thing it tells us is if you get an A in that same course, we replace the old grade. So if you had a C before Chem 101 and you get an A, that C goes away. Your science GPA elevates dramatically when you eliminate older grades from the GPA calculation. Now, if I was to add those two together, you get a very incremental bump. It's not very much, right?

Right.

And we do that because we recognize that retaking it is where you are now, which is the person we're interviewing.

Right.

And so we should replace what you can do now with what you did then when you weren't interviewing, right? And I think that's why it's important to me. And us.

Yeah, certainly. Now, just kind of branching off that conversation, NursingCAS, is that something that the institutions you're involved with, do they utilize NursingCAS?

Yeah, so we use NursingCAS at National University. Really, the reason why it's great for us is because it puts everything in one place. It's great when you have interviews, you can pop up the thing on one side, you've got their whole thing, you can go by category to GPA, everything's there, right? It's easy. And it's also all in one place, as opposed to trying to scroll through a bunch of PDFs that you got in a packet. It was a huge step up. It made reviewing applicants, because it's all standardized, so you look at one, you've looked at them all, right? Everything's in the same place. It made reviewing applicants easier. It made a standardized GPA easier, as opposed to relying on a nebulous person in registration that changes every 6 months, right?

Yeah.

It made, you know, and that's not there, it's just how it is. And it made, It made it easier for people to apply. NursingCAS, they don't charge us anything, they charge the applicants. I wanna say it's $50 an application, something like that. And that's how they make money. And every time that person attaches to a new school their application, which they fill out a basic set, and then they fill out the specific thing that we require, it's $50. So they can apply easily across many places without any concern for, you know, like, oh, did my packet get lost? Did the mail get there? Did all these things that, you know, when you're applying to stuff, you're invested, you're afraid that the mail didn't arrive. And so you're calling, you're emailing, you're asking. This eliminates that. And for us, we can sort them by every kind of imaginable filter and decide who's getting dropped into the interview bucket.

Okay.

Right then and there.

I guess one of my questions was, you know, there's been discussion about NursingCAS, the default is to average grades together. Is that something that you can manipulate from the end of the institution?

That's a great question. So what we do is we add in a question, did you take any grades again, any courses a second time, right? And when they have, we eliminate it and recalculate it ourselves. So that's how we get past that issue of NursingCAS.

I love that. Yeah, 'cause so many individuals, especially if they've taken, maybe this is a second degree and they're submitting everything that they've got. You know, they take a course that they think is really going to help them, they plug it into NursingCAS, and then it doesn't even do anything with the GPA because they're averaged together or they have so many credits.

So yeah, so we added a question just to make that clear so we could go back and look at it ourselves.

That's excellent, excellent. Now, Mike, the, the national average of experience for acceptance is about 3 years. How should applicants think about the right time to apply? I know you talked about with your program, you know, you'll take some people on the lesser side if they have a unique background, but how do How do applicants deem this is the right time to apply now?

So I think if you look at the average applicant, we'll leave out those outliers that have these interesting backgrounds, the average applicant who's applying, you should be thinking of yourself, and I don't think people, you know, have to aggrandize themselves, but they should be thinking of themselves as they've hit a point in their career where they feel like they're go-to people on their unit, wherever they work. They're experts in what they do. They've hit that point where people are asking them, where they've taken on leadership roles, where people come to them to them for, you know, what, what should change on the unit, what should change in this protocol, what should change in this care plan for patients in the ICU or wherever you're at. That's where the time is, right? So, and that means— that doesn't mean you've been on the unit for 3 years and what you've done is follow orders that you've been given every day.

Right.

Because, because, you know, a lot of people will have the argument, well, I know people who've got 10 years experience and they have no idea how any of the drugs they give work. They just press the button and follow the protocol. Yeah, that's true, those people exist. But all things being equal, the more experience you have doing any one thing, generally you're gonna be better at it. I expect everybody to be go-getters, A-type personalities, the ones that wanna know why, not just what. The non-protocol followers, the ones that are asking the RT, if you're in a place where they manage the vents, "Hey, tell me about these vent settings." Or if there's an MP or a PA or a critical care physician there, say, "Tell me about why you chose to do this versus that." those people are the people I want, right?

Yeah.

And because that's what anesthesia is at 2 in the morning when I'm by myself in the OR, there's nobody to ask. I got to figure this stuff out. And so that is part of a history that you're one of those people to figure this stuff out. And so those are the people that you really want. Yes, it's true, there's people with 10 years of experience have no idea why they're doing what they're doing. That's the minority though. And those aren't the people typically applying to anesthesia school. They're just, they're clock punchers, right? And so, that's a different subset of people. But if you've got that A-type personality who's got 1 year versus 3 years, they're not in the same category whether the 1-year person likes to hear that or not. The truth of the matter is 3 years of having that A-type personality, they'll be exponentially better at critical thinking through complex situations than the person with 1 year, even though they may be excellent. You know what I mean?

Yeah.

And I think that's a large part of it. So the idea is you should be going into the— into your— you graduate nursing school and you try to get into a unit or a high acuity ER or whatever, you should be looking to be understanding everything you do, everything that's being done with your patients in the unit or the ER or wherever you're working and be the person who understands the whys, right?

Mm-hmm.

And at 3 years, you'll be exceptional. No matter what.

Yeah.

That's the key.

I 100% agree with you. And one of the things that I teach is like, you have to find your voice. And I think you kind of alluded to this, you know, in conversation with the RTs as well as the physicians is like, you need to start kind of thinking like a provider as you get to those latter parts in the ICU and trying to find, you know, your voice and navigate the care. And don't just take the orders that you see on paper or on the computer as like, this is what I'm supposed to do. It's like, well, why am I doing this, right?

That's 100% true. I mean, when you— there's a mindset shift and I was lucky enough to have been a flight nurse for a long time where I was the provider, you know, and I wasn't writing prescriptions or writing orders, but I was making the decisions with my partner in the helicopter. And so there is a very different mind shift there, right? And it's often said that the difference between the people providing care and the people ordering the care is responsibility. Right? It's easy to, you know, doctor or PA or MP such and such tells me to do X, but it's hard when you're the person deciding on X and ultimately responsible. And in the ICU, in the ER, in the helicopter, you can be the person who's making decisions. Contrary to what maybe some detractors may say, you're not just following orders. You're providing discussions and input on the decision-making process. That's provider thinking. Right? That's critical thinking. And understanding why and suggesting, "Well, I don't know, this doesn't seem like the kind of patient that would work— that would work with, but what I've seen, the reason why I think this would work is..." Those are people that have that mindset shift that can manage independent practice.

Mike, leadership is one area where applicants often feel unsure, you know, about what exactly counts. What does leadership actually look like to an admissions committee?

Yeah, that's a good question. I think there's two types of leadership, right? There's leadership on paper and there's active leadership, right? Leadership is from the front, not from the back. And so, you know, I don't want somebody necessarily who maybe was the director of a unit. I don't think those people are involved in direct care, and direct care is what we are really kind of looking for. What I'm looking for is someone who is involved in developing protocols, who's involved in developing care sets, who's involved in developing care pathways for, say, sepsis patients by instituting new guidelines that have come out in the most recent research that, you know, all those things are really important. That are the people that are precepting new people who come into the unit, and those are the people that you want precepting. You know, it's not just like something that you got assigned. It's something you wanted to do because you're excited to train the next person to be better than you, right? That's always should be the goal of an educator. And so I think that those are the— that's the dividing line, right?

Mm-hmm.

Just because you are sitting on a committee, that's great. Tell me what you did on the committee. Because if all you were was the chair, then you were an empty chair, right? That's not leadership. If what you did was actively engage and actively be a leader, tell me how you made the changes, right? So that stuff that gets on the resume is great, might get you to the interview, but in the interview, expect me to ask, well, so tell me how you made an impact, because leaders make impact, right? They don't, you know, you do the hard things, you get engaged, you, you verbalize it, right? Because in the OR, there's no place for people who are incapable of being direct and assertive. And leaders are direct and assertive because surgeons just want to surgarize. It's not their fault. That's what they do, right?

Okay.

And we are the last line of defense for patients when it comes to safety, whether it's the right thing to do or the wrong thing to do to go to surgery. And we have to be able to not only stand up and vocalize that, to someone who's a surgeon, and by surgeon, I mean revenue generator for the facility, right? So very important, very important for all of us, both patients and the surgery side. We don't exist without them. You have to be able to stand up and verbalize it with rationale that is science-based, and you have to be assertive doing it, not like a wilting flower when you say it. Those are people who are leaders. That's how you get across the line when it comes to leadership. Yeah.

Yeah, and I feel many of our applicants are very confined by what the formal titles are. And at annual congress this past year, Dr. Drew Riddle had a presentation and he really kind of laid into that. It was like, listen, it's not just the formal titles. And that's what you mentioned in this article as well as so many people was like, well, charge and precepting, that's all I got. I'm like, well, no, like what else can you do? It's how you lead. And it's not always, and I like to use the example of if I'm in charge in the OR, and I'm running around to try and help people out and they call for help in another room. I don't go into that room and push the CRNA to the side and take over the airway. I say, "Hey, what do you need? How can I help you? Can I get drugs? Can I do this? What's going on with the patient?" I think the formal titles people really get hung up on and to your point in this article, it's not just that. And actually, I have a little excerpt here from the article that I thought was just great. And you stated, passive resumes are easy to recognize. Strong applicants show initiative that someone else can verify. Titles matter less than impact.

Yeah.

And we look for evidence that you have influenced outcomes, not just occupied roles. This was amazing. This is really a summary essentially of what you just said. But I just want to put that out there because it was very, very insightful. And I think for many people, I think it will help a lot if they can just kind of break that mold of what, you know, what leadership looks like with formal titles.

Yeah, I think a lot of people are trying to check the box, right? And they're not sure how to do that. But really it's impact, right? I don't care if you're the chair of a committee that did nothing. You know, I want to know that there was an actual impact that came from that because of your voice.

You mentioned in one area where applicants frequently fall short is their understanding of the profession itself. What are admission committees actually looking for here?

You know, I can only speak for the committees that I've sat on, but look, I am a serial advocate for our profession, right? You know, I'm unapologetically pro-CRNA. I'm not anti-anybody, not anybody. But the bottom line is, this is what I do for a living. I love doing it. I'm excited about it. I'm excited to get other people involved in it. And I'm also willing to swing to protect it. And that's the reality, right? When I— I mean, we've had applicants who have— who know nothing about the profession, who thought that you had to be supervised all the time to be safe. You know, you say that to me, there's no chance you're getting in my program from here or down the road. Um, you know, that don't realize that CRNAs can work independently and do in every state in the country. You know, that don't know anything about the politics of what's going on or the barriers to practice. Those are things, or the history to the profession, or the fact that we are the first person, people to do anesthesia, secondary only to dentists, but the first profession to do anesthesia in this country. You know, they don't know any of that. They think it's a relatively new thing. And so it's stuff like that that shows me, it telegraphs a lot of things about somebody. One, they know nothing but the salary and that's why they're applying, right?

Okay.

Look, there is nothing wrong wrong with wanting to be a CRNA to change your life financially. There's nothing wrong with that, or any job for that matter, but there should be more to it than that, right?

Mm-hmm.

And the second thing it tells me is you've put no effort into understanding what it is that you're applying for, right? Because what it is is not just a salary or a clock punching job. You know, one of the most frustrating things I think that can be, that can exist in nursing is is nursing often gets sort of labeled as the non-profession profession where people come in, they work their 3 12s, they go home and they never read a thing and they never look at a thing and they never engage in their profession. They're apathetic. And then they go back and punch their clock. They don't— work isn't a profession, it's work, right? They're just getting it done. Those aren't the people that typically apply to anesthesia school, but some do. And so those are the people that we just don't want in the profession, frankly, because they'll be clock punchers, they'll be staring at their watch every minute of every day, you know, they will never read anything, they'll never maintain the skill level. Those things are really important because every CRNA is a representation of nurse anesthesiology, you know, every CRNA all the time.

Yeah.

It's just the reality. And so, you know, we want people who are engaged, who wanna be engaged, they become ANARN members, they put the effort into learning about the profession, they wanna go to a conference, the ANA Midyear, the Annual Congress, or their local state conferences to learn more and engage with people who are doing it every day and are fighting for it to continue to exist, right? Because if you're not at the table, you're on the menu in the economics of healthcare. And so the bottom line is, is we want more people who are at the table. And so— What telegraphs that greatly is when they come to an interview and they know all kinds of things about the profession. It's shocking how amazingly informed some people come.

Mm-hmm.

And that is really impressive because that's another part of what's important to becoming a nurse anesthesiologist is being informed, involved, and engaged. And there's lots of ways to do those things. They don't have to be on the ANA board, but there's many ways to be engaged, informed, involved, and advocate for the profession. We want to see that.

Yep, yep, definitely. And, and I feel like over the last couple years I've, I've been keyed in on it more and more. I was doing a, a mock interview not too long ago, and a young lady had, with her shadowing experience, she had listed the hospital that she worked at and the anesthesia model that it was. And, and, uh, she had anesthesia care team model, you know, medically directed, uh, medically supervised, independent practice. And right away I'm like, all right, she's just using buzzwords to try and impress me here. So Right away, I laid in, what's the difference between this? What's the difference between that? And she nailed it. And I was like, wow. I mean, that's impressive when they— not only did she have it listed, but she understood why it was important to list it. And that really blew me away. And I think we're getting just more and more engaged nurses that are coming through that really want to dive headfirst in this profession. And to your point, I mean, that's exactly who I want to be with at mid-year assembly, at annual congress, at all these various things. Because they care and they want to be there. You mentioned that the interview is essentially a stress test. Why is that such an important part of the process?

So there's a couple of reasons why, right? The first thing is, every day coming to the OR is going to be a stress test when you're training. That's just the reality, right? There's going to be lots of personalities. Some of them are not going to be especially touchy-feely, and they're going to be aggressively asking questions and pimp questions and all over people. Some will not be great. Some will be great. People who are going to fold in an interview are not gonna do well there, right?

Mm-hmm.

It is going to telegraph their success in very tough situations because we can't, as a program, control what happens in the OR with preceptors, right? These people, and I think that's a misconception from people who apply, we don't own them. They're not employed by the university. These are people who are volunteering to train our nurse anesthesia residents, and so they're taking it upon themselves to pay it forward, and that is an exceptionally benefit to the profession, right? Physician anesthesiologists that are putting the time in to train our people for the future because we might take care of them one day. You know, I appreciate all of them. And so, you know, but they're difficult personalities in the OR, not just them, but surgeons, circulators, techs, everybody, right? Especially when you're on the bottom of the totem pole. And so we stress test that rapid-fire questions under pressure in a time frame, right? So that's one thing that we're doing. The second thing we're doing besides just stress testing their ability to manage pressure and stress, is we're asking clinical-based questions to see if what they think they know, they know, right? So if you work in a respiratory ICU and you don't know when I ask you about vent settings, or I ask you about a complicated ARDS patient what the vent setting should be, and the answer is— and this is something we've heard many times— well, the RT manages the vent, we don't. Yeah, I don't, I don't care.

Exactly.

That's irrelevant to me. What you've just said to me is that's not my job. And if there's one set of words I hate the most, that's it. And so the patient is your job. Understanding the entire global process of what's occurring in the treatment of that patient, taking care of that patient is your job. And that includes the vent settings, even if you're never allowed to touch the vent by policy of the facility. And there's someone there who's an expert, and that's the RT you should be asking, right?

Mm-hmm.

Learn about it, right? Or, well, you know, the provider ordered X and it says this range, so I just set the range up. And we ask them, here's all these different, here's a patient in this particular critical situation, what drips would you use and what would be the dose range? Well, you know, I don't really know which drips, you know, or you don't understand the receptors or why it works or what it does to preload and afterload, if you don't understand how it changes the cardiac output or impacts the cardiac output, that's a problem, right?

Mm-hmm.

I don't, surface level is easy. I could teach the janitor to do all these things, right? To intubate, to put a central line in, all this stuff are easy. And it's just a function of practice, right? What I want are people who understand why they're doing what they're doing and then can critically think about why they might not not do something, right? Because it's always easy to do something, you know. Medical decision management is about when knowing not to do something, right? That's understanding the big picture, not just this one moment in time. So I— that's where a lot of the interview kind of stress tests people. It stress tests what they think they know, you know. I mean, I can't tell you how many times we put up a second-degree type 1 rhythm, very basic ACL strip, and people could not get And it's not because it's a complicated rhythm, it's because they think they're being tricked. But they look at the rhythm and think, "Well, it can't be that." And then they, "Well, I don't know, it could be this, could be this." And then they never answer and they never say, "I don't know," or they never just pick a road and go down it and say it's a secondary type 1.

Mm-hmm.

And what ends up happening is that translates to us that you're struggling under stress and instead of critically thinking through what you're seeing, and ignoring the fact that you think it could be a trick, you're getting lost in the weeds, right?

Yep, you just get pulled, yep, yep.

Yep, and so that is a stress test, you know what I mean? Because at 2 in the morning when you're by yourself and everything's going to crap on a very sick patient who's an emergency that there's no pre-op done on because you took them right from the ER to the OR, there's no time to flip through a book or ask ChatGPT, That doesn't exist in those moments. So that's when the expectation is you understand the depth of why you do what you do and why you do not do some things, right? Protocols are for safety, but sometimes protocols can be dangerous. And so there's a reality there that that's the depth of knowledge that we're looking for.

What are some other common interview mistakes that you see aside from that's not my job and failing the stress test?

Yeah, there's a couple. I mean, I think people get real nervous and that's normal, right? You get nervous, this is your shot, you know, kind of thing, I get it. And they ramble. And so one of the negatives there is the expectation is concise, critical thinking thoughts, right? So understanding how to do that, it's an art. You learn it over time by engaging with a lot of people in conversation, right? It's sometimes critical conversations like, you know, Five Dysfunctions of a Team is a great book, Emotional Intelligence 2.0, Crucial Conversations. "Conversations" is a great book. It's all part of a communication course I developed. And all of those things teach you how to listen and reframe in a real concise way that hits the points. That's gonna be real important in your anesthesia program, both on the didactic side for presentations, but also in the OR. And so I think that one thing that people do is ramble. They verbalize their thought process in a way that's— it's disjointed. That's something I see a lot. Another thing I see a lot that people do is they struggle with something and instead of saying, "You know what, I don't know," which is a valid answer.

Sure.

They just try, they dig the hole deeper, you know, going way off kilter with something that's totally incorrect instead of just saying, "You know what, I don't know." No, you know, and those are the probably the two biggest things we see the very most because look, interviews are time constrained for us too. We're going to interview 100 people for 30 spots over a 3-day period. So the reality is, is this is— these are 10 to 15-minute interviews maximum, right?

Mm-hmm.

And so we expect to get as much out of that as possible in a shortest period of time as possible to help inform us as to who to select for the program. You don't always get it right, but you can get a lot of information from those things in an interview.

Mike, is there— do you afford the applicants opportunity to ask questions at the end of the interview? And if so, is there— I know this was a hot topic not too long ago and you touched on it briefly. I think it might have been the second article, part 2 that you wrote. But the questions that people are asking, is that helping to set them apart? Is that showing another layer of them? Is that leaving a bad taste in— in your mouth based on the questions that they ask?

I would say there's a couple of answers to that, and it depends on where the questions are coming from. So if there's one thing that, that globally pisses off teams of people on admissions committee, it's hearing the exact same question from multiple applicants because we know it's come from a question list from some sort of you know, group, right? You know, that's out there. And I'll tell you one question that really makes us angry. What are you going to do to help me be successful? Well, the answer there, my friend, is nothing. You are going to do it to be successful. That's what doctoral training is, right?

Yep.

What I'm going to do is provide you all the tools, all the knowledge, and all the experience in our program from our faculty to make you successful and all the training. But the person who's going to do it and be successful is you, right? And so, you know, the answer to— and I've literally said that to people. That was one of those questions that came from some prep thing. And I've literally said, the answer here is nothing. We're not gonna do anything to make you successful. You're gonna be successful on your own because welcome to doctoral training. It's self-directed in many ways. So if they come with questions like that that are from some list, we identify them within a couple of interviews and it just gets irritating.

Yep.

And program directors and faculty across the country 3, talk about this stuff. So we all hear the same list, right?

Exactly.

Then, so that is bad, right? Freeform questions, bad. When someone can be really separated out is when they start to ask things that are really intuitive. Things like, you know, I've read a lot about how CRNAs can practice independently. Does your program, like, what is the program doing to help get me in to see that and be involved in independent or autonomous collaborative style practice, as opposed to anesthesia care team supervised medically directed practice. Nothing wrong with that practice. But when they ask questions specifically like that about something that they're interested in, that asks like, how do we manage that? I think that gets my attention, right?

Yeah.

Because it tells me a multitude of things. One, they've learned about the profession. Two, they've realized that what they don't wanna do is necessarily be in one practice or another, or at the very least they want to know that they can experience the options so that they can make a decision, right? Because if you never live it, you— you know, Edelman has this great quote that I love: you can't be what you can't see, right? So if you, if you go to a program— and this is not to say these programs are bad— that never rotates to an autonomous or independent CRNA site, you may know empirically that those exist, but you don't understand what it's like what it's like to be the only person making the decisions. And you only get it when you rotate to those places. So if someone asks a question like that, it tells me they've thought about these things, right?

Mm-hmm.

They've thought, well, I don't know that I wanna work independently, but what I do wanna do is know for sure what it is, what it's like, how it operates, you know, when you're expected to just do the thing, right? And so I think there's very intuitive style questions like that that tell me that they've put a lot of thought this. I love that. Like, that gets my attention.

Yeah, no, I love that too. It's just so forward-thinking and really prioritizing their education too. I think there's that— there's a big component to that specific question that you had mentioned. Um, Mike, you know, as we wrap this up, one of the things I wanted to ask you, you know, if I'm an aspiring CRNA listening to this today and did not receive an interview this cycle, what would you want them to take away from this conversation?

You know, I love the Jersey Shore. I grew up in that era. And the Situation said it best, "The comeback should always be greater than the setback." Right? And you can all— failure doesn't mean the end. You should fail forward. It's a longstanding— anyone who's successful has failed 1,000 times for every success. Success, right? Or 100 times or whatever the number is, right? But what you do is you learn from that moment where you didn't get what you wanted. You know, everyone has a feeling of loss. You get over that, you deal with it, and then, you analyze it, you review what was missing, and you become better, right?

Mm-hmm.

And the way you become better is, and this is why, like, you know, for National University, I set up a frequently asked questions page. I have a, you know, here's Here's what we expect to get in the program. You didn't get an interview. Here's the frequently asked questions about what you could do differently, where the most common reasons why people don't do well, you know, and don't get accepted, et cetera. You know, I put that up there because it's the most common things.

Yeah.

These are the things that people struggle with the most or what they can do to be better. And when that happens, you know, I will tell you that without a doubt, I am much more likely to take a repeat applicant than anyone else into the program. Because there is a grit that comes with that, that tells me that that person is truly capable. You know what I mean? And when they go back and they take what I've written or what we've told them and they come back with it again and they come back better and they come back elevating their application, that tells me that when they're asked what they're going to do for success, the answer is whatever it takes. And so not making it through the first interview or not getting an interview or not getting past the interview, that's not failure in the traditional sense. That's data, right? You've been given information, you've been given the pathway then to what you can do better. It's data to inform the next step to come back stronger and then be accepted and have success. And that's part of the process. And that's true in every single facet of your life, whether it's dating, right? Whether it's business, whether it's friendships, whether it's family, whether it's education, is every time something doesn't go your way, that's a data point that you can be better from. And that's what I would tell them.

I love that, Mike. That's such an insightful article and such an insightful conversation. And even throwing in the quote from The Situation there, That's great. But, but, you know, you've really— this, this article alone in this conversation has shed so much light on this entire journey for so many of our aspiring CRNAs. And I can't thank you enough for joining us today and help— helping to support, you know, all of our aspiring CRNAs. I— you're such a voice in, in our field, and, and I appreciate all you have to have to offer here. And keep writing those Substacks because they are pure gold here.

Yeah, I appreciate it. You know, part of my mantra is pay it forward. Uh, we all stand on the shoulders of giants, and it's a professional citizenship goal to be involved, pay it forward, and do it for free. And so those are, those are part of the things that I've always done myself because people did it for me. And so I feel an obligation to do so, which I think a lot of people in our profession do, which is great.

Absolutely. Absolutely. Well, thank you very much, Mike. And until next time, take care.

See ya.